IT’S BAAACKKKK!!!
October 1, 2021
By Lisa Germain, DDS, MScD
As summer began, it seemed that there was hope that we were finally seeing the light at the end of the tunnel. Many previously closed retail stores reopened and people started to feel more comfortable with inside table seating at restaurants. Travel soared to pre pandemic levels and as we eased into our old familiar rhythm, we began to throw caution (and our masks) to the wind. The pandemic was over…until it wasn’t.
Unfortunately, it has become clear that our sense of freedom from worry had been ill timed as the highly transmissible Delta variant of Sars-CoV2 became rampant. This whiplash effect from the premature abandonment of personal protection and social distancing, to the current crucial need to rebalance safety and sanity has left many of us with more questions than answers.
As I write this article, the CDC has reported that there are about 130,000 new cases each day that is almost double the levels from last summer at its peak. Hospitalizations have reached their highest levels since the winter. Vaccination rates still lag with only about half of Americans fully vaccinated. Since the Delta Variant became a household name, daily vaccination rates have only risen modestly to about 700,000 doses per day. As of this writing, the country has recorded 36.7 million coronavirus cases and 621,000 deaths since the beginning of the pandemic.
In my home state of Louisiana, the number of new cases has shattered all previous records as critically ill patients overwhelm hospital intensive care units averaging 5,800 new cases a day. To my horror, Louisiana has the most new cases and deaths per capita and is part of a surge in Southern states with low vaccination numbers. Gov. John Bel Edwards temporarily reinstated a mask mandate earlier this month but did not shut down indoor dining or institute other restrictions. This begs the question, “Can you still get COVID-19 if you’re fully vaccinated?”
At this point it is difficult to know whether the information that you read and hear is fact or fiction, accurate or acrimonious, scientific or speculative, anecdotal or double blind. Statistical significance is meaningless if you or a loved one happens to be in the unfortunate few who have had severe adverse side effects from the vaccination. At the forefront of the confusion are the emotionally charged debates regarding the vaccine itself, FDA approval status, and mandatory masking. The mainstream media as well as social media are both culpable because they both frequently slant what they report for the purposes of either sensationalism or personal agenda only reporting half facts or intentionally taking things out of context. In an effort to clear away the detritus, I did a deep dive into the New England Journal of Medicine, the CDC website, EEOC regulations and HIPPA Laws to help answer some of the pressing questions that I had about what to do now to protect myself, my family, my office team, and my patients.
Q: What accounts for the exponential growth in recent infections of patients with Covid-19?
A: The Delta Variant accounts for 90% of all current infections in the US. This strain of the virus is considered 6-8 times more transmissible than the original virus. It is affecting people of all ages, young and old. It has a much shorter incubation time and symptoms appear much faster. Children are at great risk because the vaccine is not approved for use on anyone younger than 12 years old.
Q: Are people still getting sick from the original virus?
A: Yes, however it is currently the minority of reported cases.
Q: Will the vaccine prevent me from getting sick
A: You can get infected even if fully vaccinated, however if vaccinated and there is a breakthrough infection, the illness tends to be mild and in > 30% of the cases without symptoms. The majority of current hospitalizations and deaths in (90%) of the cases occur on people who have not been vaccinated.
Q: If you are fully vaccinated and get a breakthrough infection, can you transmit the disease to another person.
A: Yes. If you are infected, you can be contagious.
Q: Are the vaccines effective against the Delta Variant?
A: All of the three approved vaccines are less effective against the Delta Variant than they are in preventing infection from the original strain of SARS-CoV-2. The statistics state that efficacy against the Delta Variant is between 42-68%, not the > 90% that was originally reported by some sources. Early data suggests that the Moderna vaccine is slightly more effective against the Delta Variant, with respect to breakthrough infection. However, there is no difference in the need for hospitalizations or in the death rate for people who are vaccinated with either the Pfizer or Johnson and Johnson vaccines as compared to Moderna. More data analysis is necessary to be able to see the rate of breakthrough infections with the various vaccinations.
Q: How long am I covered for if I have been fully vaccinated?
A: Data is rapidly being accumulated on the Pfizer and the Moderna Vaccines. There is less information on the Johnson and Johnson vaccine. There is a decrease in neutralizing antibodies over time, but the levels remain reasonable >6 months after vaccination. If you are concerned, a simple blood test is available to determine your antibody level. Make sure you get an “antibody” test which tests for immune titers. (The antigen test will tell you if you have a current infection, however the accuracy of the home tests are laden with false positives and false negatives.)
Q: What about a third shot or a booster?
A: Currently the third shot is being recommended for patients that are immunocompromised. According to the CDC Yellow Book*, this list includes: ·
- Active or recent treatment for solid tumor and hematologic malignancies
- Receipt of solid-organ or recent hematopoietic stem cell transplants
- Severe primary immunodeficiency
- Advanced or untreated HIV infection
- Active treatment with high-dose corticosteroids, alkylating agents, antimetabolites, tumor-necrosis blockers, and other biologic agents that are immunosuppressive or immunomodulatory
- Chronic medical conditions such as asplenia and chronic renal disease may be associated with varying degrees of immune deficit
On August 13th, the CDC recommended that people with moderately to severely compromised immune systems receive an additional dose of mRNA COVID-19 vaccine (Pfizer or Moderna vaccine) at least 28 days after the second dose. People who are immunocompromised don’t always build the same level of immunity after vaccination the way non-immunocompromised people do and may benefit from an additional dose to ensure adequate protection against COVID-19.
Q: What if I am immunocompromised and I had the Johnson and Johnson vaccine?
A: The booster shots should be one of the two mRNA vaccinations. There is still insufficient data to recommend an additional Johnson and Johnson vaccine and the statistics to determine whether it will increase antibody titer after a second dose is currently not available.
Q: If I had the Moderna vaccine can the booster shot be Pfizer and vice versa?
A: Yes. It is okay to mix the vaccine platforms.
Q: What if I want to get a third shot and I am not immunocompromised?
A: A third shot is not recommended for a fully vaccinated individual who is not immunocompromised. However, the CDC does not require that patients have a letter from their doctor or any other evidence of medical need. You will be required to fill out paper work attesting to the fact that you qualify.
Q: How do I get a third vaccination?
A: You can get a booster vaccine by making an appointment with your local pharmacist. They will provide you with the form for self-attestation and administer the shot.
Q: Are there risks associated with a third dose of vaccine?
A: There is limited information about receiving a third dose of vaccine. However, the new recommendation will yield more data regarding the safety, benefits, and efficacy of this supplemental booster shot. To date, the reactions reported following a third inoculation were similar to the two dose series. The most common of these are pain and muscle soreness at the injection site, as well as a period of malaise. Most often these are reported as mild, however, as was noted following the two dose series, serious side effects can occur but they are rare.
Q: What is “long COVID”?
A: “Long COVID” is the terminology used when a patient’s symptoms from a COVID infection last longer than 12 weeks and cannot be explained by any other cause. These range from severe to mild and include, but are not limited to, exhaustion, shortness of breath, heart palpitations, brain fog, inability to taste or smell, and joint pain.
Q: Are the effects of “Long COVID” worse than a quickly resolving infection?
A: University College London (UCL) identified 200 symptoms affecting 10 organ systems in people with “long COVID,” at higher levels than in people who were fully recovered. They include hallucinations, insomnia, hearing and vision changes, short term memory loss and speech and language issues. Others have reported gastrointestinal and bladder problems, changes to periods and skin conditions. While the severity of the symptoms varies, many with this longer duration infection have been left unable to perform tasks like showering, grocery shopping and remembering words. “Long COVID” becomes increasingly likely with age, and it is twice as common in women.
Q: What causes “Long COVID”?
A: There are 2 theories:
- The infection makes some people’s immune systems go into overdrive, attacking not just the virus but their own tissues as well. That can happen in people who have very strong immune responses. The virus itself getting into and damaging our cells might explain some symptoms like brain fog and a loss of smell and taste, while damage to blood vessels in particular could lead to heart, lung and brain problems.
- Fragments of the virus could remain in the body, possibly lying dormant and then becoming reactivated. This happens with some other viruses, like herpes and the Epstein Barr virus that causes glandular fever. However, there isn’t much evidence for this happening with COVID at the moment.
Q: Can the vaccine help patients suffering from “Long COVID”?
A: Roughly half of people with “Long COVID” reported an improvement in their symptoms after being vaccinated; possibly by resetting their immune response or helping the body attack any remaining fragments of the virus. Vaccination can also help prevent people contracting the virus and developing long COVID in the first place.
Q: Can the CDC make vaccinations mandatory?
A: No. They are a government agency, therefore do not have the authority to regulate in that arena.
Q: Can I, as an employer, mandate vaccinations for all employees?
A: Currently, employers can legally require employees to get vaccinated, assuming they can establish it is a legitimate job requirement. However, they need to make reasonable accommodations for workers who cannot take the vaccine because of disabilities or religious reasons. As health care providers, we could make a very convincing ethical case that all team members should be vaccinated for the protection of their co-workers and our patients. According to the EEOC, you can ask everyone whether they have been vaccinated and request proof of vaccination. When an employee has not been vaccinated, however, the employer must be careful not to pry as to why, particularly in situations in which vaccinations are voluntary and not required for the job.
Q: Is it legal in all states for us to mandate vaccinations for all of our employees?
A: A handful of states currently have pending legislation that addresses employment practices mandating COVID-19 vaccination. Once in law, state legislation will supersede federal guidance on the matter. It is imperative that you follow your state guidelines regarding this issue if legislation passes that makes the federal guidelines moot.
Q: Can you ask a potential employee if they are vaccinated?
A: Yes. However, when screening new applicants for a position, and if hiring decisions are based even partially on vaccine status, the employer needs to hold all current employees in similar positions to the same standards. If the hiring is done based solely on vaccination status, possible ethical questions could come into play because a potential employer may not be aware that a qualified but unvaccinated applicant could not take the vaccine because of a disability or religious reason. The “Catch 22” is that you are not permitted to ask why.
Q: Is it a HIPPA violation to ask patients to provide proof of vaccination?
A: NO. This is a common misconception. HIPAA, (Health Insurance Portability and Accountability Act of 1996) and its subsequently added Privacy Rule include provisions to protect a person’s identifying health information from being shared without their knowledge or consent. The law, though, only applies to specific health-related entities, such as insurance providers, health-care clearinghouses, health-care providers and their business associates. But, it’s not really a prohibition on asking; it is a prohibition on sharing the information.
The accuracy of this information is based on what I consider reliable sources as of August 21, 2021, however it does not account for individual opinion or interpretation of the subject matter. Please do your own due diligence before implementing any best practices.
*2013 CDC Yellow Book on General Best Practices for Vaccination of People with Altered Immunocompetence
REFERENCES
Bergwerk, M et al. Covid-19 Breakthrough Infections in Vaccinated Health Care Workers July 28, 2021, DOI: 10.1056/NEJMoa2109072
Hall Victoria G., et al. (2021),Randomized Trial of a Third Dose of mRNA-1273 Vaccine in Transplant Recipients. N Engl J Med DOI: 10.1056/NEJMc2111462
Lopez, J et al. Effectiveness of Covid-19 Vaccines against the B.1.617.2 (Delta) Variant August 12, 2021, N Engl J Med 2021; 385:585-594
DOI: 10.1056/NEJMoa2108891
Phillips, S. et al., Confronting Our Next National Health Disaster — Long-Haul COVID August 12, 2021, N Engl J Med 2021; 385:577-579